Concussion management is a different kind of healthcare. We hear talk about the evolution of medicine, things like medical homes, integrated care, and the importance of a “multidisciplinary approach,” but concussion care seems to represent the touchpoint of the conflict between the ideal vs. the practical and the jockeying for what seems to be the ever-increasing competition for sports medicine revenues.

But what is multidisciplinary, really? Seems to me that the answer is more than just semantics, as it seems to get at the heart of what’s wrong with most of the big-business approaches to managing concussions that highlight widescale baseline testing and one-size-fits-all care.

The term “multidisciplinary” is used to represent the need to involve various disciplines (medical specialties) to manage an illness or injury. With concussions affecting so many different systems – medical, cognitive, affective – that seems to make sense.

Yet, I think what we really mean – and need – is interdisciplinary, not multidisciplinary, since the former better represents the team approach to achieve the common, SHARED goals that should be our primary focus in helping injured athletes return to what they love. To best achieve that, however, we need to pay attention to the language that we use to represent what we do, starting with intradisciplinary vs. multidisciplinary, along with we vs. I, and our vs. my. As my northern colleague Dr. Michael Ellis recently tweeted, the best concussion care is harmonized. The epitome of a team approach. After all, isn’t that what true sports medicine should be about?

Heading into my 5th fall sports season since moving back to the south, and the 5th fall sports season since passage of Georgia’s “Concussion Law” that mandates concussion education for high-school athletes and coaches, it is admittedly disappointing to realize that there has not been much change in the prevailing local concussion management guidelines distributed to Georgia schools that provide the blueprint for the return-to-learn and to play.

Fortunately, however, we have the recent CDC guidelines – published in the last few weeks – that reflect the changes that have been practiced by sports-concussion experts and sports neuropsychologists for several years, and as a supplement to the Berlin Guidelines and statements from related professional organizations that also contradict much of the current standard practices. Among the highlights:

Avoid prolonged rest! “Rest” does not mean to sit in a dark room, avoid electronics, tests, and socializing, and staying out of school for more than a couple of days. Rather, it means managing, manipulating, modifying, activities or triggers that lead to a worsening of symptoms. Big difference there!

Offer symptom-specific school-based supports. These are not “one-size-fits-all” but should be individualized based on each individual’s symptom-profile, context, risk factors, and history.

Do consider risk factors for prolonged recovery, and refer out to specialists if symptoms are prolonged.

There is no data to support the utility of widespread, large-scale baseline testing. When it is administered, it should be under structured testing conditions with some guidance or oversight by experts in neurocognitive / neuropsychological testing who can attest to the validity and the reliability of each child’s scores.

There is no medical basis to remove cell phones, limit coloring to child vs. adult coloring books, carbo-load, or to recommend certain fixed portions of school days or no testing, all recommended to students I’ve seen over the last few weeks. Again, management needs to be individualized and symptom-specific, with modifications as needed to avoid activities associated with symptom increase – that is, it’s not black/white, all/nothing, or limited to what’s listed on a pre-printed form, though checklists are always good places to start.

For the second time in as many weeks, I’ve heard about “a good friend who’s a psychologist who says that their reports never take more than 2 weeks.” While my knee-jerk reaction is “Wow, I wish I could do that!” my more measured response is this: I’m perfectly OK with the fact that while I typically provide reports within the timelines I promise at the outset, my reports take longer. There are reasons for that.

As a neuropsychologist, my expertise is in brain-behavior relationships, which are also informed by my expertise as a school psychologist and my life experiences as a mother and student. I administer all tests myself, including as much historical and collateral reporting as I can gather, and don’t rely on testing support from a trainee, psychometrist, or other in-office staff. This enables me – and my clients — to reap the benefits of all of the qualitative, diagnostic and interpretive observations that go into my reports, though other methods are more efficient.

Synthesizing, interpreting, and reconciling all of these sources of data within the context of what we know about the brain, learning, and diagnostic formulations, just takes time… not just the number of hours logged writing up my findings, but also in the time it takes to ruminate on what I’ve found, to question, test hypotheses, confer and collaborate with colleagues, and ruminate some more. Then, there’s the time it takes to extract the information I consider most relevant for this child, those questions, that context, at this particular point in time. I don’t use canned templates and test-by-test descriptions. Nor do I cut and paste the impressions of employees. That’s why my reports take longer, but it’s also why they are comparatively long, detailed and highly individualized.

I don’t start to write reports until all records are received, irrespective of the extent to which families may think they are relevant. After all, how can I evaluate the nature of each individual’s history and look for patterns over time with pieces missing? Even the most seemingly innocuous of teacher comments and grade reports can yield significant value to me in my qualitative approach, and I don’t presume to have all the answers until I’ve been able to systematically review and evaluate everything as a whole.

Is that time-consuming and sometimes tedious? You bet. If report-writing speed is a priority for someone, I’m probably not the best fit for them. But if parents want the value of a fully informed, deep and integrated understanding of their child’s unique strengths, weaknesses, challenges and opportunities, this is what it takes.

It’s that time of year again – the air’s getting crisper, pumpkin spice is everywhere, and the calls for help with prolonged post-concussion symptoms are picking back up.

As a mom and as a sports neuropsychologist, it just makes me nuts!

While I certainly don’t want to minimize the importance of the brain or taking brain injuries seriously, I see more harm to students come from mismanagement of the initial injury than the actual injury itself, and I just hate to hear about it when it happens.

It’s commonly accepted that most older students – high school, college age – recover fully within 2-3 weeks, with 90% achieving full recovery in a month. While there are identifiable risk factors associated with prolonged recovery, in my practice I see mis-management as the most common reason for protracted recoveries.

For example, rest does NOT mean isolating students in dimly lit rooms and removing social contact and the means for connecting socially. That’s more likely to lead to a worsening of symptoms in many cases, due to social isolation or kids simply ignoring such unnecessarily draconian directives altogether. Rather, rest simply means listening to one’s body, and making the necessary lifestyle – home and school – adjustments to minimize symptom exacerbation with ongoing activity.

Gradual return to school does NOT mean returning to just a few classes and working as hard as ever – it more often means adjusting workload, classroom activities, and how the school facilities are navigated, in a manner that allows for gradual re-entry, social connections and, again, managing symptom exacerbation. There is no one-size-fits-all checklist that is most effective; management of the return-to-learn should be individualized, based on each student’s unique symptom profiles and triggers – and while that’s not a complicated process, but one handout for all typically isn’t adequate, either.

…and how about the role of computerized testing? It can be a tool for assessing injury impact and recovery progress, but it’s also one of many tools that we can use, and should not be used in isolation or by persons without extensive training in neuropsychological assessment – that is, more training than one may get from a weekend workshop and a few videos. And, by the way, there’s no such thing as a “passing score” or “normal score” on ImPACT – test interpretation should be individualized, taking a variety of factors into account over/above the average score ranges for one’s age and gender.

As a developmental neuropsychologist who specializes in concussions and a nationally certified school psychologist, my expertise is in brain-behavior relationships, and in understanding the functional impact of sports concussions on behavior, learning, and physical activity. As a sports neuropsychologist specializing in concussion management for more than a decade, and having just returned from the Berlin Conference, I know more than a little bit about current research and best practice standards, too, but the most important part of what I do is listening to each client’s symptoms, concerns, and needs, helping to return athletes of all ages to their playing fields, classrooms, and workplaces as quickly and safely as possible, using good science and common sense.

See the Resources page on my website for additional resources. Weekday and weekend appointments available.

I had a wonderful chance encounter this morning with a local high school football coach. When I told him that I enjoy talking to athletes about sports-related concussions, he asked me what, exactly, I talk about. My answer? “Common sense.”

July in Georgia marks the start of another football season and with that, a likely surge in the hysteria, folklore, and marketing dollars that have become part of the sports-concussion landscape. One of the most important parts of my job in managing concussions is to help spread accurate information – about what, exactly, concussions are and how best to manage them, so that when they do occur, the secondary fallout is minimized and youth athletes are able to return to the classrooms and playing fields as quickly and safely as possible.

So what, exactly, do I say?

First, I want to make sure we’re all speaking the same language and that athletes actually know what a concussion is. Despite the mandatory concussion education for GA high school athletes since 2013, I still find that injured athletes – many of whom see a few other healthcare providers before they get to my office – still don’t know what, exactly, a concussion is. And, if they don’t know what it is, how are they supposed to be able to manage it well?

When I explain what a concussion is, I also include discussion of how it affects the athlete.. for example, how an offensive lineman’s quality of play can be impacted by slowed reaction time… or what happens to a quarterback when dizziness spikes with rapid head and eye movements… or how about that cheerleading flyer who’s dizzy and thinking more slowly than usual? Add to that the increased pressure of a few AP classes and the cumulative effects of only 5-6 hours of sleep/night, and athletes can start to see that hiding their symptoms may not be the way to stay in the game longer or to continue support their teammates.

Concomitantly, I also talk about the role of an athlete’s common sense, self-awareness, and self-control in minimizing symptom increase during recovery, along with the importance of workload and classroom management. I acknowledge how our typical suck-it-up-and-play approach to sports-injury management can be counter-productive in facilitating recovery from concussion, and how we manage concussions very differently than we manage other sports injuries.

Finally, I also talk about risk management, and what athletes can do to minimize their own risk of concussion and prolonged recoveries. This can include some discussion of things like heads-up tackling, equipment and field conditions, for example. I also emphasize the importance of sleep, hydration, and good conditioning, what it means to “listen to your body,” and how to truly look out for teammates. Coaches and athletic trainers play key roles here, too, in creating and maintaining a culture that promotes player safety in addition to the competitive edge.

In a perfect world, conversations like this would be starting again across our state’s locker rooms, playing fields and gyms as pre-season practices begin. Let me know how I can help start the conversation for your team.

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Concussion management is a different kind of healthcare. We hear talk about the evolution of medicine, things like medical homes, integrated care, and the importance of a “multidisciplinary approach,” … [Read More...]